Issue link: https://beckershealthcare.uberflip.com/i/1494056
20 EXECUTIVE BRIEFING 2 EXECUTIVE BRIEFING SPONSORED BY Coding complexities that are costing your practice and how to document them correctly W hat's the difference between M51.09 and M51.04? It's just one number, right? Well, for these two ICD- 10 codes, that one number means the difference between a specified and unspecified code. It also likely means the difference between getting a first-pass denial on your claim from a payer and getting reimbursed. That's just one example of the seemingly countless coding nuances that your orthopedic practice has to be mindful of every day. These small nuances can have a big impact on the health of patients, physicians and entire practices. Incorrect or underspecified documentation can result in surgery denials, unnecessary tests and mistaken procedures. It can also impact your bottom line as a result of inaccurate E/M levels and reimbursement, claim denials, and even audits. With thousands of codes and constant rule changes, no one person can possibly keep up with the particularities of every payer. Being aware of the most common ones can help. Here are two coding complexities that we see often in the orthopedic practices we work with at Robin and how you can document them correctly. Distinguishing between an uncomplicated and complicated acute injury or illness According to the American Medical Association (AMA), an uncomplicated acute injury/illness is a recent or new short-term problem with a low risk of morbidity. There is little to no risk of mortality with treatment, and a full recovery without functional impairment is expected. It is a problem that is normally self-limiting or minor, but it is not resolving in a definite or prescribed way. Examples of uncomplicated acute injuries/illnesses include: • Cystitis • Allergic rhinitis • Simple sprain The AMA defines a complicated acute injury/illness as a problem that is extensive, has treatment options that are multiple and/ or associated with risk of morbidity, or requires treatment that includes evaluation of body systems that are not directly part of the injury. Examples of complicated acute injuries/illnesses include: • Head injury with a brief loss of consciousness • Bone that is partially/completely fractured in any way • Pain with no known injury, which an MRI reveals is a result of nerve damage that requires surgery An intuitive way to help ensure you're correctly distinguishing between an uncomplicated and complicated acute injury/ illness is to ask yourself a series of questions while doing your documentation. For an issue that appears to be uncomplicated, ask yourself: • Will this issue heal on its own without intervention? • If yes, you're right. It's most likely uncomplicated. • Were there any other organ systems involved? • If yes, it's most likely complicated. • Was there more than one treatment option available to the patient? • If yes, it's most likely complicated. • Was the treatment option conversative? • If it was an in-office procedure, it's most likely uncomplicated. • If it was a surgical procedure, it's most likely complicated. For an issue that appears to be complicated, ask yourself the following questions. If the answer to some or all of them is "yes," it's most likely complicated. • Were there multiple non life threatening injuries addressed? • Was there an evaluation of neurovascular or cardiovascular structures while examining a patient for a fracture? • Was there a need to evaluate other body systems not related to the injury?